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护理中微小操作失误的实时报告

Real-Time Reporting of Small Operational Failures in Nursing Care.

作者信息

Stevens Kathleen R, Ferrer Robert L

机构信息

School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.

Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.

出版信息

Nurs Res Pract. 2016;2016:8416158. doi: 10.1155/2016/8416158. Epub 2016 Nov 8.

DOI:10.1155/2016/8416158
PMID:27895940
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5118534/
Abstract

Addressing microsystem problems from the frontline holds promise for quality enhancement. Frontline providers are urged to apply quality improvement; yet no systematic approach to problem detection has been tested. This study investigated a self-report approach to detecting operational failures encountered during patient care. . Data were collected from 5 medical-surgical units over 4 weeks. Unit staff documented operational failures on a small distinctive Pocket Card. Frequency distributions for the operational failures in each category were calculated for each hospital overall and disaggregated by shift. Rate of operational failures on each unit was also calculated. . A total of 160 nurses participated in this study reporting a total of 2,391 operational failures over 429 shifts. Mean number of problems per shift varied from 4.0 to 8.5 problems with equipment/supply problems being the most commonly reported category. . Operational failures are common on medical-surgical clinical units. It is feasible for unit staff to record these failures in real time. Many types of failures were recognized by frontline staff. This study provides preliminary evidence that the Pocket Card is a feasible approach to detecting operational failures in real time. Continued research on methodologies to investigate the impact of operational failures is warranted.

摘要

从一线解决微系统问题有望提高质量。一线医疗服务提供者被敦促应用质量改进措施；然而，尚未对系统的问题检测方法进行测试。本研究调查了一种自我报告方法，用于检测患者护理过程中遇到的操作失误。在4周内从5个内科-外科病房收集数据。病房工作人员在一张独特的小卡片上记录操作失误。计算了每家医院总体上每个类别操作失误的频率分布，并按班次进行了分类。还计算了每个病房的操作失误率。共有160名护士参与了本研究，在429个班次中共报告了2391次操作失误。每个班次的平均问题数从4.0个到8.5个不等，设备/供应问题是最常报告的类别。内科-外科临床病房的操作失误很常见。病房工作人员实时记录这些失误是可行的。一线工作人员识别出了多种类型的失误。本研究提供了初步证据，表明小卡片是实时检测操作失误的可行方法。有必要继续研究调查操作失误影响的方法。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/0c21beb86346/NRP2016-8416158.004.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/148bc8c45c12/NRP2016-8416158.001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/a7b2b9b5826d/NRP2016-8416158.002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/64986b29b1a9/NRP2016-8416158.003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/0c21beb86346/NRP2016-8416158.004.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/148bc8c45c12/NRP2016-8416158.001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/a7b2b9b5826d/NRP2016-8416158.002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/64986b29b1a9/NRP2016-8416158.003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/afec/5118534/0c21beb86346/NRP2016-8416158.004.jpg

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